The mortality rate of septic shock remains high. The guidelines of the Surviving Sepsis Campaign were published in 2004 and were revised in 2008. Steroid therapy is prominent in the guidelines but remains controversial. In this review, steroid therapy for septic shock is discussed with various landmark papers.

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Small interfering RNAs (siRNAs) and microRNAs (miRNAs) are functional RNA molecules that have recently emerged as important regulators of gene expression at the posttranscriptional or translational level. The RNA interference effects of siRNA on gene expression make it a valuable research tool for knocking down the expression of genes in mammalian cells in vitro and in vivo enabling the elucidation of molecular mechanisms underlying human diseases. Endogenous miRNAs are involved in a variety of physiological and pathological processes in humans. In this mini-review we first address the synthesis, mechanisms of action, and functions of siRNAs. Then, we focus on recent advances and technologies in miRNA and protein research of the human placenta. Next, we discuss the clinical applications of miRNA in lung cancer. We also touch on "long" noncoding RNAs from intergenic regions of the human genome. This review article is based on a presentation given at a symposium entitled Basic and Clinical Studies on Functional RNA Molecules for Advanced Medical Technologies held at Nippon Medical School in Tokyo, Japan, on November 7, 2009.

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Aims: To explore whether intravaginal treatment with urinary trypsin inhibitor (UTI) prevents preterm delivery in patients in preterm labor with increased levels of granulocyte elastase in cervical secretions.
Methods: The subjects were patients in preterm labor with increased levels of granulocyte elastase in cervical secretions from 16 to 33 weeks gestation. Maternal and neonatal outcomes were compared between patients receiving UTI treatment (UTI group; n=33) and those not receiving UTI treatment (control group; n=40).
Results: In patients receiving UTI, the mean gestational age at delivery was greater than that in the control group (37.8 vs. 35.6 weeks, p=0.003), and the rates of premature delivery before 34 and 37 weeks gestation were lower (3% vs. 20%, p=0.028; and 18% vs. 47%, p=0.008, respectively). The percentage of neonates weighing more than 2,500 g was significantly higher in the UTI group, with no neonates weighing less than 1,500 g. The neonatal hospitalization rate was lower in the UTI group (9% vs. 42%, p=0.001).
Conclusion: In patients in preterm labor with a high elastase concentration in cervical secretions, treatment with UTI reduced the risk of preterm delivery and improved neonatal outcomes.

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In peritoneal dialysis (PD) the dialysate is introduced into the peritoneal cavity, and the peritoneal membrane is used as the dialysis membrane. In PD, patients exchange the dialysate by themselves through the connection tube attached to the indwelling catheter that is inserted into the peritoneal cavity. Microbes may enter the peritoneal cavity during dialysate exchange, and, therefore, peritonitis is a potential complication of PD. To prevent microbial contamination, the connection tube tip is generally sealed with a protection cap containing povidone-iodine (PVP-I) during the dwelling time. This cap is designed to make direct contact with the tube tip so that microbes attached during dialysate exchange are killed by the next dialysate exchange. However, if excess PVP-I flows into the peritoneal cavity and is absorbed into the body, the complications, including thyroid dysfunction, peritoneal inflammation, and fibrous thickening, can develop.
Therefore, in this study, a new manual connection system (Zero System, JMS Co., Ltd., Hiroshima, Japan) for continuous ambulatory peritoneal dialysis was investigated to confirm that the PVP-I solution within the protection cap of the new system would not flow into the fluid passing through the tube. An experiment was also performed to confirm that the microbes on the connector tip become completely nonviable after attachment of the cap for 3 hours. The cap is fitted with a sponge containing a 10% PVP-I solution, the same as for the conventional cap system. However, the system is designed to achieve disinfection without contact, unlike with the conventional system, in which disinfection is achieved by direct contact of the PVP-I-containing sponge with the open end of the attached connector. The test results demonstrated that adequate disinfection with this system can be achieved by the next exchange, while avoiding entry of PVP-I into the peritoneal cavity from the cap.
The results suggest that the use of this connection system can avoid adverse reactions arising from the absorption of PVP-I and prevent the onset of peritonitis caused by microbial invasion of the peritoneal cavity.

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We examined whether the incidence of neonatal respiratory disorders has increased with the increased rate of elective cesarean delivery in twin pregnancies. We reviewed the obstetric records of 292 twin deliveries with vertex presentation of the first twin after 37 weeks' gestation at our hospital from 2000 through 2008. The study period was divided into 3 parts as follows: period 1: 2000 through 2002 (n=76); period 2: 2003 through 2005 (n=104); and period 3: 2006 through 2008 (n=112). We compared the rate of elective cesarean delivery due to maternal request and the incidence of transient tachypnea of the newborn (TTN). There has been a significant increase in rate of elective cesarean delivery (period 1: 18%; period 2: 25%; period 3: 48%) over the past several years. This increase was observed to be due to an increase in maternal requests for elective cesarean delivery. However, there were no significant differences in the incidence of TTN in the 3 periods [period 1: 7.2%; period 2: 6.7%; period 3: 8.0%]. The recent increase in the rate of cesarean delivery did not cause the increase in the incidence of neonatal respiratory disorders in twin pregnancies.

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Enhanced glycolysis is important for oncogenesis and for the survival and proliferation of cancer cells in the tumor microenvironment. Recent studies have also shown that proinflammatory cytokine signaling, such as that mediated by nuclear factor κB and signal transducer and activator of transcription 3 (STAT3), is important for the generation of inflammation-associated tumors. However, the link between inflammation and enhanced glycolysis has not been identified. In the present study, we found that the proinflammatory cytokine interleukin (IL)-6 enhanced glycolysis in mouse embryonic fibroblasts and human cell lines. Moreover, STAT3 activated by IL-6 enhanced the expression of the glycolytic enzymes hexokinase 2 and 6-phosphofructo-2-kinase/fructose-2,6-bisphosphatase-3 (PFKFB3). Ectopic expression of PFKFB3 enhanced glycolysis, suggesting that the IL-6-STAT3 pathway enhances glycolysis through the induction of these enzymes. Our findings may provide a novel mechanism for inflammation-associated oncogenesis.

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A number of recent reports have highlighted the usefulness of laparoscopic surgery for pancreatic surgery; however, the procedure is not yet standard because of its technical challenges. Using an endoscopic surgical spacer (SECUREA^TM) that we developed, we performed laparoscopic enucleation of a pancreatic tumor in a patient with pancreatic mucinous cystadenoma. The SECUREA is a polyurethane sponge with a radiopaque marker. It is elliptic-cylindrical and measures 6.5 cm on the major axis, 3.5 cm on the minor axis, and 2 cm in height. Herein, we report the intraoperative findings and examine the usefulness of SECUREA for laparoscopic enucleation. The spacer was introduced into the abdominal cavity through a 12-mm trocar, and was grasped with forceps to isolate or extend organs and tissues, thereby ensuring a safe and relatively uncontaminated surgical field. In addition, the high absorptiveness and water-holding capacity of the sponge facilitated removal of exudate, which created a clearer operative field and reduced the technical challenges of drainage manipulation. Indeed, replacement of the sponge was unnecessary because it returned to its original state after the liquid it contained had been aspirated. Our findings suggest that the SECUREA increases safety and reduces the technical difficulties of laparoscopic enucleation.

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We report the case of a patient with paraduodenal hernia diagnosed incidentally during an operation for transverse colon cancer. The patient was a 77-year-old woman who complained of dizziness. Laboratory data revealed no abnormal findings except slight anemia. Barium enema and colonoscopic examination revealed an irregular surfaced mass, about 5.0 cm in size, located near the flexure of the spleen of the transverse colon. A biopsy of the mass was performed, and a moderately differentiated adenocarcinoma was diagnosed. In April 2009, following the diagnosis of transverse colon cancer, laparotomy was performed, which revealed that a few loops of the jejunum were herniated through the orifice into the space posterior to the transverse mesocolon. Moreover, the jejunal loops were located right between a shifted left branch of the middle colic artery and ascending left colic artery. There were no ischemic changes in the jejunum. These findings were consistent with a left paraduodenal hernia associated with transverse colon cancer. The scheduled left hemicolectomy was performed in addition to a radical operation of the left paraduodenal hernia. The abdominal computed tomography (CT) images were reviewed postoperatively. The scan projection radiogram obtained by CT revealed a packing of jejunal loops in the middle of the abdomen. Abdominal CT revealed ascending left colic artery at the left edge of a packing of jejunal loops. The patient was discharged from our hospital 14 days after the surgery without any complications. Left paraduodenal hernias are rare and constitute less than 0.4% of all intestinal obstructions. Retrospectively reviewed, the preoperative CT is suggestive. In addition to the packing of jejunal loops in the middle of the abdomen, ascending left colic artery was clearly observed at the left edge of the packing of jejunal loops, which indicates left paraduodenal hernia.

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We report a rare case of venous hemangioma (VH) of the anterior mediastinum in a 56-year-old man admitted to our hospital because of hematemesis. Systemic examinations were performed and chest computer tomography (CT) revealed a 1.5-cm sized small nodule with contrast enhancement in the thymus. Both CT and magnetic resonance imaging (MRI) suggested a solid tumor such as a thymoma or neurogenic tumor rather than a vascular neoplasm. A partial thymectomy including this nodule by video-assisted thoracic surgery (VATS) was performed. Histological examination showed VH. There was no recurrence with no further treatment.

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The limulus test, which has been established as a test for endotoxin measurement, is associated with problems, including that posed by the presence of a response inhibitor factor and the longer time needed for the measurement of low concentrations. On the other hand, the technique of direct hemoperfusion with a polymyxin B immobilized fiber column (DHP-PMX) was developed in Japan in 1994 and has been used for the control of endotoxemia in septic shock. The limulus test, which is a common endotoxin measurement test, has several problems with regard to sensitivity. Therefore, this test is no longer used to determine the effectiveness of DHP-PMX. Here, we describe a patient presenting with colonic perforation who recovered from septic shock with DHP-PMX. This treatment effect was reflected by a decrease in plasma endotoxin levels as demonstrated more readily with endotoxin scattering photometry assay than with the standard limulus test. We conclude that endotoxin measurement with endotoxin scattering photometry is superior to nephelometry in patients with endotoxemia.

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We report on a patient with spontaneous rupture of a nonaneurysmal left common iliac artery in whom hemorrhagic shock developed. A 64-year-old woman presented with hemodynamic collapse accompanied by sudden abdominal pain. She was transported to the emergency department. Angiography showed a penetrating atherosclerotic ulcer in the left common iliac artery. Emergency surgery was performed with graft replacement (14 × 7 mm woven Dacron graft). Severe calcification was observed in the left common iliac artery, and an ulcer of the iliac artery was confirmed as the source of hemorrhage. The postoperative course was uneventful, and the patient was discharged on postoperative day 14. We conclude that rupture may occur in patients with severe atherosclerotic change, even in the absence of aneurysm.

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